Objectives The Wells rule is often used in primary care to rule out pulmonary embolism (PE), but its efficiency is low as many referred patients do not have PE. In this study, we evaluated in primary care an alternative and potentially more efficient diagnostic strategy—the YEARS algorithm; a simplified three-item version of the Wells rule combined with a pretest probability adjusted D-dimer interpretation. Design In this comprehensive prospective diagnostic validation study, primary care patients suspected of PE were enrolled by their general practitioner. All three YEARS items were collected in addition to D-dimer results, and patients were followed for 3 months to establish the final diagnosis. Setting Primary care in the Netherlands. Participants 753 patients with suspected acute PE were included. Five patients (0.7%) were lost to follow-up. Main outcome measures Failure rate (number of PE cases among patients classified by the algorithm as ‘PE ruled-out’) and efficiency (fraction of patients classified as ‘PE probable/further imaging needed’). Results Prevalence of PE was 5.5% (41/748 patients). In total, 603 patients were classified as ‘PE ruled-out’ by the YEARS algorithm (532 with zero YEARS items and a D-dimer<1000 ng/mL and 71 with≥1 positive YEARS item and a D-dimer<500 ng/mL), resulting in an efficiency of 80.6% (603/748 patients, 95% CI 77.6% to 83.4%). Of these patients, three patients had a diagnosis of non-fatal PE during 3 months follow-up, all three with zero YEARS items and D-dimer between 500 and 1000 ng/mL, resulting in an overall diagnostic failure rate of 0.50% (3/603 patients, 95% CI 0.13% to 1.57%). In the patients categorised as ‘imaging needed’ (n=145), a total of 38 (26.2%) were indeed diagnosed with PE. Conclusions Our study suggests that acute PE can be safely ruled out in 80% of patients by the YEARS algorithm in a primary care setting, while only 20% of patients required referral to hospital care for imaging tests. In those classified as ‘imaging needed’, PE was present in about one in every four patients, demonstrating a high detection proportion.

Objectives There are substantial barriers to initiate advance care planning (ACP) for persons with chronic-progressive disease in primary care settings. Some challenges may be disease-specific, such as communicating in case of cognitive impairment. This study assessed and compared the initiation of ACP in primary care with persons with dementia, Parkinson’s disease, cancer, organ failure and stroke.Design Longitudinal study linking data from a database of Dutch general practices’ electronic health records with national administrative databases managed by Statistics Netherlands.Setting and participants Data from general practice records of 199 034 community-dwelling persons with chronic-progressive disease diagnosed between 2008 and 2016.Outcome measure Incidence rate ratio (IRR) of recorded ACP planning conversations per 1000 person-years in persons with a diagnosis of dementia, Parkinson’s disease, organ failure, cancer or stroke, compared with persons without the particular diagnosis. Poisson regression and competing risk analysis were performed, adjusted for age, gender, migration background, living situation, frailty index and income, also for disease subsamples.Results In adjusted analyses, the rate of first ACP conversation for persons with organ failure was the lowest (IRR 0.70 (95% CI 0.68 to 0.73)). Persons with cancer had the highest rate (IRR 1.75 (95% CI 1.68 to 1.83)). Within the subsample of persons with organ failure, the subsample of persons with dementia and the subsample of stroke, a comorbid diagnosis of cancer increased the probability of ACP. Further, for those with organ failure or cancer, comorbid dementia decreased the probability of ACP.Conclusions Considering the complexity of initiating ACP for persons with organ failure or dementia, general practitioners should prioritise offering it to them and their family caregivers. Policy initiatives should stimulate the implementation of ACP for people with chronic-progressive disease.

Background Systematic reviews of preventive, non-disease-specific primary care trials for older people often report effects according to what is thought to be the intervention’s active ingredient. Aim To examine the effectiveness of preventive primary care interventions for older people and to identify common components that contribute to intervention success. Design and setting A systematic review and meta-analysis of 18 randomised controlled trials (RCTs) published in 22 publications from 2009 to 2019. Method A search was conducted in PubMed, MEDLINE, Embase, Web of Science, CENTRAL, CINAHL, and the Cochrane Library. Inclusion criteria were: sample mainly aged ≥65 years; delivered in primary care; and non-disease-specific interventions. Exclusion criteria were: non-RCTs; primarily pharmacological or psychological interventions; and where outcomes of interest were not reported. Risk of bias was assessed using the original Cochrane tool. Outcomes examined were healthcare use including admissions to hospital and aged residential care (ARC), and patient-reported outcomes including activities of daily living (ADLs) and self-rated health (SRH). Results Many studies had a mix of patient-, provider-, and practice-focused intervention components (13 of 18 studies). Studies included in the review had low-to-moderate risk of bias. Interventions had no overall benefit to healthcare use (including admissions to hospital and ARC) but higher basic ADL scores were observed (standardised mean difference [SMD] 0.21, 95% confidence interval [CI] = 0.01 to 0.40) and higher odds of reporting positive SRH (odds ratio [OR] 1.17, 95% CI = 1.01 to 1.37). When intervention effects were examined by components, better patient-reported outcomes were observed in studies that changed the care setting (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.17, 95% CI = 1.01 to 1.37), included educational components for health professionals (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.27, 95% CI = 1.05 to 1.55), and provided patient education (SMD for basic ADLs 0.28, 95% CI = 0.09 to 0.48). Additionally, admissions to hospital in intervention participants were fewer by 23% in studies that changed the care setting (incidence rate ratio [IRR] 0.77, 95% CI = 0.63 to 0.95) and by 26% in studies that provided patient education (IRR 0.74, 95% CI = 0.56 to 0.97). Conclusion Preventive primary care interventions are beneficial to older people’s functional ability and SRH but not other outcomes. To improve primary care for older people, future programmes should consider delivering care in alternative settings, for example, home visits and phone contacts, and providing education to patients and health professionals as these may contribute to positive outcomes.

BackgroundIn Europe, opioid use has surged, largely due to prescriptions for chronic non-malignant pain (CNMP). General practitioners (GPs) and community pharmacists (CPs) play a major role in opioid prescribing for non-malignant pain. Exploring their personal beliefs and practices might reveal underlying mechanisms to identify measures that could halt the further escalation of opioid use.MethodsGuided by the health belief model, a survey was designed and distributed nationwide to examine the practices and beliefs of GPs and CPs in the domains: threats, benefits, barriers and self-efficacy. The results of GPs and CPs were compared at the statement level using chi-square analysis.ResultsOf 214 GPs and 212 CPs who completed the survey, the majority agreed that too many opioids are used in the treatment of chronic non-malignant pain (66.8% GPs and 66.5% CPs). Furthermore, they were concerned about the addictive potential of opioids (83.1% GPs and 71.7% CPs). In general, both professions have concerns about opioid use. GPs report a slightly higher degree of self-efficacy and perceive fewer benefits from opioids in treating CNMP. GPs and CPs valued the recommended measures to reduce opioid prescribing, yet less than half actively implement these strategies in their clinics.ConclusionGPs and CPs believe that opioids are being used too frequently to treat CNMP. However, both professions lack the actions to improve opioid-related care. GPs and CPs require education, collaboration and tools to implement guidelines on non-malignant pain and opioids.SignificanceThis study, guided by the health belief model, reveals that general practitioners and community pharmacists have serious concerns about opioid use in chronic non-malignant pain. Despite shared concerns, both professions differ in their beliefs about opioid benefits and perceived self-efficacy. Both professions have in common that they value recommended measures to reduce opioid prescribing. Also, they both struggle to implement strategies, emphasizing the urgent need for education, collaboration and tools to align practices with guidelines on non-malignant pain and opioids.

BACKGROUND Over the past decades, opioid prescriptions have increased in the Netherlands. The Dutch general practitioners' guideline on pain was recently updated and now aims to reduce opioid prescriptions and high-risk opioid use for non-cancer pain. The guideline, however, lacks practical measures for implementation. OBJECTIVE This study aims to determine practical components for a tool that should assist Dutch primary care prescribers and implements the recently updated guideline to reduce opioid prescriptions and high-risk use. METHODS A modified Delphi approach was used. The practical components for the tool were identified based on systematic reviews, qualitative studies, and Dutch primary care guidelines. Suggested components were divided into Part A, containing components designed to reduce opioid initiation and stimulate short-term use, and Part B, containing components designed to reduce opioid use among patients on long-term opioid treatment. During three rounds, a multidisciplinary panel of 21 experts assessed the content, usability, and feasibility of these components by adding, deleting, and adapting components until consensus was reached on the outlines of an opioid reduction tool. RESULTS The resulting Part A consisted of six components, namely education, opioid decision tree, risk assessment, agreements on dosage and duration of use, guidance and follow-up, and interdisciplinary collaboration. The resulting Part B consisted of five components, namely education, patient identification, risk assessment, motivation, and tapering. CONCLUSIONS In this pragmatic Delphi study, components for an opioid reduction tool for Dutch primary care-givers are identified. These components need further development, and the final tool should be tested in an implementation study.

BACKGROUND:Anticholinergic burden has been associated with adverse outcomes such as falls. To date, no gold standard measure has been identified to assess anticholinergic burden, and no conclusion has been drawn on which of the different measure algorithms best predicts falls in older patients from general practice. This study compared the ability of five measures of anticholinergic burden to predict falls. To account for patients' individual susceptibility to medications, the added predictive value of typical anticholinergic symptoms was further quantified in this context. METHODS AND FINDINGS:To predict falls, models were developed and validated based on logistic regression models created using data from two German cluster-randomized controlled trials. The outcome was defined as "≥ 1 fall" vs. "no fall" within a 6-month follow-up period. Data from the RIME study (n = 1,197) were used in model development, and from PRIMUM (n = 502) for external validation. The models were developed step-wise in order to quantify the predictive ability of anticholinergic burden measures, and anticholinergic symptoms. In the development set, 1,015 patients had complete data and 188 (18.5%) experienced ≥ 1 fall within the 6-month follow-up period. The overall predictive value of the five anticholinergic measures was limited, with neither the employed anticholinergic variable (binary / count / burden), nor dose-dependent or dose-independent measures differing significantly in their ability to predict falls. The highest c-statistic was obtained using the German Anticholinergic Burden Score (0.73), whereby the optimism-corrected c-statistic was 0.71 after interval validation using bootstrapping and 0.63 in the external validation. Previous falls and dizziness / vertigo had the strongest prognostic value in all models. CONCLUSIONS:The ability of anticholinergic burden measures to predict falls does not appear to differ significantly, and the added value they contribute to risk classification in fall-prediction models is limited. Previous falls and dizziness / vertigo contributed most to model performance.

De inclusie van deelnemers voor wetenschappelijke onderzoeken in de eerstelijnszorg valt bijna altijd zwaar tegen. Dit artikel beschrijft hoe een onderzoek naar een nieuwe diagnostische strategie daardoor bijna mislukte. Een alternatieve inclusieprocedure bleek echter wonderwel te werken.

Background In the general population, an increase in low-density lipoprotein cholesterol (LDL-C) predicts higher cardiovascular disease risk, and lowering LDL-C can prevent cardiovascular disease and reduces mortality risk. Interestingly, in cohort studies that include very old populations, no or inverse associations between LDL-C and mortality have been observed. This study aims to investigate whether the association between LDL-C and mortality in the very old is modified by a composite fitness score. Methods A 2-stage meta-analysis of individual participant data from the 5 observational cohort studies. The composite fitness score was operationalized by performance on a combination of 4 markers: functional ability, cognitive function, grip strength, and morbidity. We pooled hazard ratios (HR) from Cox proportional-hazards models for 5-year mortality risk for a 1 mmol/L increase in LDL-C. Models were stratified by high/low composite fitness score. Results Composite fitness scores were calculated for 2 317 participants (median 85 years, 60% females participants), of which 994 (42.9%) had a high composite fitness score, and 694 (30.0%) had a low-composite fitness score. There was an inverse association between LDL-C and 5-year mortality risk (HR 0.87 [95% CI: 0.80-0.94]; p < .01), most pronounced in participants with a low-composite fitness score (HR 0.85 [95% CI: 0.75-0.96]; p = .01), compared to those with a high composite fitness score (HR = 0.98 [95% CI: 0.83-1.15]; p = .78), the test for subgroups differences was not significant. Conclusions In this very old population, there was an inverse association between LDL-C and all-cause mortality, which was most pronounced in participants with a low-composite fitness scores.

Background: As populations age, multimorbidity (the presence of two or more chronic morbidities) is increasingly more common. These evolving demographics demand further research into the identification of morbidity patterns in different settings as well as the longitudinal effects of these patterns.Methods: Prospectively collected data on 12,755 older persons aged 65+ years were derived from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS, www.topics-mds.eu). Latent class analyses were performed to identify unobserved relationship patterns between morbidities in older persons. Using linear mixed models, the average difference in health-related quality of life (EQ-5D) and general quality of life scores (Cantril's Self Anchoring Ladder) as well as limitations in Activities of Daily Living and Instrumental Activities of Daily Living (ADL/IADL) were examined over a 12-month period.Results: Five multimorbidity patterns were identified: sensory (n = 3882), cardio-metabolic (n = 2627), mental health (n = 920), osteo-articular (n = 4486), and system decline (n = 840). Relative to older persons in the sensory group, multimorbidity patterns did not have a strong effect on health-related quality of life, general quality of life or ADL/IADLs over a one-year period.Conclusions: The observed multimorbidity patterns are similar to others based on different methodologies and study populations. When examining the effect of such patterns on quality of life, the EQ-5D and Cantril's Ladder may be insufficient outcome measures. Further investigations into the prognostic value of morbidity patterns would be of benefit.

Background: Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs.Methods: The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe.Results: SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life.Conclusions: We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.

BACKGROUND:In patients clinically suspected of having pulmonary embolism (PE), physicians often rely on intuitive estimation ("gestalt") of PE presence. Although shown to be predictive, gestalt is criticized for its assumed variation across physicians and lack of standardization. OBJECTIVES:To assess the diagnostic accuracy of gestalt in the diagnosis of PE and gain insight into its possible variation. METHODS:We performed an individual patient data meta-analysis including patients suspected of having PE. The primary outcome was diagnostic accuracy of gestalt for the diagnosis of PE, quantified as risk ratio (RR) between gestalt and PE based on 2-stage random-effect log-binomial meta-analysis regression as well as gestalts' sensitivity and specificity. The variability of these measures was explored across different health care settings, publication period, PE prevalence, patient subgroups (sex, heart failure, chronic lung disease, and items of the Wells score other than gestalt), and age. RESULTS:We analyzed 20 770 patients suspected of having PE from 16 original studies. The prevalence of PE in patients with and without a positive gestalt was 28.8% vs 9.1%, respectively. The overall RR was 3.02 (95% CI, 2.35-3.87), and the overall sensitivity and specificity were 74% (95% CI, 68%-79%) and 61% (95% CI, 53%-68%), respectively. Although variation was observed across individual studies (I2, 90.63%), the diagnostic accuracy was consistent across all subgroups and health care settings. CONCLUSION:A positive gestalt was associated with a 3-fold increased risk of PE in suspected patients. Although variation was observed across studies, the RR of gestalt was similar across prespecified subgroups and health care settings, exemplifying its diagnostic value for all patients suspected of having PE.

Abstract Background (Instrumental) activities of daily living ((I)ADL) questionnaires are often used as a measure of functioning for different purposes. Depending on the purpose, a measurement of functioning that includes subjective patient perspectives can be relevant. However, it is unclear to what extent (I)ADL instruments capture self-perceived functioning. Objective Explore what functioning means to older persons after a hip fracture and assess the extent to which (I)ADL instruments align with self-perceived functioning. Design Qualitative interview study with framework analysis. Setting Prospective cohort study on recovery after a hip fracture among older persons in a hospital in a large city in the west of the Netherlands. Subjects Eighteen home-dwelling older persons (≥70 years) who had a hip fracture 6–12 months ago. Methods Telephone interviews about functioning before and after the hip fracture were coded and analysed using the framework method. Results The activities mentioned by participants to be part of their self-perceived functioning could be split into activities necessary to maintain the desired level of independence, and more personal activities that were of value to participants. Both the ‘independence activities’ and the ‘valued activities’ mentioned went beyond the activities included in (I)ADL questionnaires. Due to various coping strategies, limitations in activities that are measured in the (I)ADL questionnaires did not necessarily lead to worse self-perceived functioning. Conclusion Self-perceived functioning differs from functioning measured with (I)ADL questionnaires in the items included and the weighing of limitations in activities. Thus, (I)ADL instruments alone are not enough to measure functioning from the perspective of the older person.

OBJECTIVES:Previous findings suggest a vascular foundation underlying apathy, but transdiagnostic and prospective evidence on vascular apathy is scarce. This study examines the association between vascular disease and the presence and development of apathy symptoms in the very old. METHODS:Four cohorts of the Towards Understanding Longitudinal International older People Studies (TULIPS)-consortium were included in a two-staged, individual participant data meta-analysis using generalized linear mixed models. Vascular disease was defined as a history of any clinical atherosclerotic pathology (angina pectoris, myocardial infarction, intermittent claudication, transient ischemic attack, stroke or related surgeries) and was related to apathy symptoms as repeatedly measured by the Geriatric Depression Scale (GDS-3A ≥2) over a maximum of 5 years. RESULTS:Of all 1868 participants (median age 85 years old), 53.9% had vascular disease and 44.3% experienced apathy symptoms. Participants with vascular disease had a 76% higher risk of apathy symptoms at baseline (odds ratio (OR) 1.76, 95% confidence interval (CI) 1.32-2.35), irrespective of depressive symptoms and only partially explained by stroke. Conversely, there was no association of vascular disease with the occurrence of apathy symptoms longitudinally, both in those with apathy at baseline (OR 1.00, 95% CI 0.84-1.20) and without (OR 0.96, 95% CI 0.84-1.09). CONCLUSIONS:Vascular disease in the very old is associated with apathy symptoms cross-sectionally, but not proven longitudinally, independent of depressive symptoms. These findings query a vascular cause underlying apathy symptoms. However, the consistency of our cross-sectional findings in direction and magnitude across the TULIPS-consortium do emphasize international relevance of the interplay of vascular factors and apathy in advanced age, which meaning needs further unravelling.

Background: Daily functioning is known to decline after a hip fracture, but studies of self-reported functioning before the fracture suggest this decline begins before the fracture. Objective: Determine whether change in functioning in the year before a hip fracture in very old (80+) differs from change in those without a hip fracture. Design: Two-stage individual patient data meta-analysis including data from the Towards Understanding Longitudinal International older People Studies (TULIPS)-consortium. Setting: Four population-based longitudinal cohorts from the Netherlands, New Zealand and the UK. Subjects: Participants aged 80+ years. Methods: Participants were followed for 5 years, during which (instrumental) activities of daily living [(I)ADL] scores and incident hip fractures were registered at regular intervals. Z-scores of the last (I)ADL score and the change in (I)ADL in the year before a hip fracture were compared to the scores of controls, adjusted for age and sex. Results: Of the 2,357 participants at baseline, the 161 who sustained a hip fracture during follow-up had a worse (I)ADL score before the fracture (0.40 standard deviations, 95% CI 0.19 to 0.61, P = 0.0002) and a larger decline in (I)ADL in the year before fracture (-0.11 standard deviations, 95% CI -0.22 to 0.004, P = 0.06) compared to those who did not sustain a hip fracture. Conclusions: In the very old a decline in daily functioning already starts before a hip fracture. Therefore, a hip fracture is a sign of ongoing decline and what full recovery is should be seen in light of the pre-fracture decline.

Objectives: While randomized controlled trials have proven the benefits of blood pressure (BP) lowering in participating octogenarians, population-based observational studies suggest an association between low systolic blood pressure (SBP) and faster overall decline. This study investigates the effects of BP-lowering treatment, a history of cardiovascular diseases (CVD), and cognitive and physical fitness on the associations between SBP and health outcomes in the very old. Methods: Five cohorts from the Towards Understanding Longitudinal International older People Studies (TULIPS) consortium were included in a two-step individual participant data meta-analysis (IPDMA). We pooled hazard ratios (HR) from Cox proportional-hazards models for 5-year mortality and estimates of linear mixed models for change in cognitive and functional decline. Models were stratified by BP-lowering treatment, history of CVD, Mini-Mental State Examination scores, grip strength (GS) and body mass index (BMI). Results: Of all 2480 participants (59.9% females, median 85 years), median baseline SBP was 149 mmHg, 64.3% used BP-lowering drugs and 47.3% had a history of CVD. Overall, higher SBP was associated with lower all-cause mortality (pooled HR 0.91 [95% confidence interval 0.88-0.95] per 10 mmHg). Associations remained irrespective of BP-lowering treatment, history of CVD and BMI, but were absent in octogenarians with above-median MMSE and GS. In pooled cohorts, SBP was not associated with cognitive and functional decline. Conclusion: While in the very old with low cognitive or physical fitness a higher SBP was associated with a lower all-cause mortality, this association was not evident in fit octogenarians. SBP was not consistently associated with cognitive and functional decline.

PURPOSE To investigate variability in older people’s outcomes according to general practitioner (GP) and practice characteristics in New Zealand and the Netherlands. METHODS We used data from 2 primary care–based, cluster-randomized, controlled trials to separately fit mixed models of unplanned admission rates, functional ability, and quality of life (QOL) and examine variation according to GP- and practice-level characteristics after adjusting for participant-level characteristics. For the New Zealand sample (n = 3,755 aged 75+ years in 60 practices), we modeled 36-month unplanned admission rates, Nottingham Extended Activities of Daily Living (NEADL) scale, and QOL domain ratings from the brief version of the World Health Organization Quality of Life assessment tool. For the Netherlands sample (n = 3,141 aged 75+ years in 59 practices), we modeled 12-month unplanned admission rates, Groningen Activity Restriction Scale scores, and EuroQOL 5 dimensions (EQ-5D) summary index. RESULTS None of the GP or practice characteristics were significantly associated with rates of unplanned admissions in the New Zealand sample, but we found greater rates of admission in larger practices (incidence rate ratio [IRR], 1.45; 95% CI, 1.15-1.81) and practices staffed with a practice nurse (IRR, 1.74; 95% CI, 1.20-2.52) in the Netherlands sample. In both samples, differences were consistently small where there were significant associations with function (range, −0.26 to 0.19 NEADL points in the New Zealand sample; no associations in the Netherlands sample) and QOL (range, −1.64 to 0.97 QOL points in New Zealand; −0.01 EQ-5D points in the Netherlands). CONCLUSIONS In the absence of substantial differences in older people’s function and QOL, it remains unclear whether intriguing GP- or practice-related variations in admission rates represent low- or high-quality practice.

Unpredictable disease trajectories make early clarification of end-of-life (EoL) care preferences in older patients with multimorbidity advisable. This mixed methods systematic review synthesizes studies and assesses such preferences. Two independent reviewers screened title/abstracts/full texts in seven databases, extracted data and used the Mixed Methods Appraisal Tool to assess risk of bias (RoB). We synthesized findings from 22 studies (3243 patients) narratively and, where possible, quantitatively. Nineteen studies assessed willingness to receive life-sustaining treatments (LSTs), six, the preferred place of care, and eight, preferences regarding shared decision-making processes. When unspecified, 21% of patients in four studies preferred any LST option. In three studies, fewer patients chose LST when faced with death and deteriorating health, and more when treatment promised life extension. In 13 studies, 67% and 48% of patients respectively were willing to receive cardiopulmonary resuscitation and mechanical ventilation, but willingness decreased with deteriorating health. Further, 52% of patients from three studies wished to die at home. Seven studies showed that unless incapacitated, most patients prefer to decide on their EoL care themselves. High non-response rates meant RoB was high in most studies. Knowledge of EoL care preferences of older patients with multimorbidity increases the chance such care will be provided.

BackgroundThe impact of health problems on daily life and consequent treatment goals differ from person to person, particularly for older people with multiple health problems. Personalized care in general practice can help address these health problems, but evaluation of its effects remains difficult. In rehabilitation, a common approach to the evaluation of personalized care is Goal Attainment Scaling. This feasibility study assesses whether goal attainment scaling can also be applied to the evaluation of personal care for community-dwelling older people in general practice.MethodsGeneral practices were invited to participate in this longitudinal, observational feasibility study. Practice nurses and general practitioners received training in care plans and goal attainment scaling. They were each asked to create care plans and goal attainment scales for patients (aged ≥75 years) and to carry out evaluations at three and six months. Professionals and patients both completed a short questionnaire to evaluate their experiences regarding the (dis)advantages of goal attainment scaling.ResultsProfessionals (n=10) and patients (n=23) were able to set goals and scales (n=57) for problems across five health domains (somatic, functional, social, psychological and communicative), but experienced difficulties formulating goals and corresponding goal attainment scaling levels. Reported benefits of goal attainment scaling were 1) important problems were addressed, 2) patients were involved and motivated to attain goals, and 3) evaluation was straightforward once a scale was created. Disadvantages were 1) difficult for older people, 2) time-consuming and complex for clinical practice.ConclusionsGoal attainment scaling shows potential benefit for clinical practice and general practice research in terms of the setting and evaluation of goals for community-dwelling older persons. Further research is needed to develop more standardized and less time-consuming goal attainment scaling methods.

OBJECTIVE:To explore factors that potentially impact external validation performance while developing and validating a prognostic model for hospital admissions (HAs) in complex older general practice patients.STUDY DESIGN AND SETTING:Using individual participant data from four cluster-randomised trials conducted in the Netherlands and Germany, we used logistic regression to develop a prognostic model to predict all-cause HAs within a 6-month follow-up period. A stratified intercept was used to account for heterogeneity in baseline risk between the studies. The model was validated both internally and by using internal-external cross-validation (IECV).RESULTS:Prior HAs, physical components of the health-related quality of life comorbidity index, and medication-related variables were used in the final model. While achieving moderate discriminatory performance, internal bootstrap validation revealed a pronounced risk of overfitting. The results of the IECV, in which calibration was highly variable even after accounting for between-study heterogeneity, agreed with this finding. Heterogeneity was equally reflected in differing baseline risk, predictor effects and absolute risk predictions.CONCLUSIONS:Predictor effect heterogeneity and differing baseline risk can explain the limited external performance of HA prediction models. With such drivers known, model adjustments in external validation settings (eg, intercept recalibration, complete updating) can be applied more purposefully.TRIAL REGISTRATION NUMBER:PROSPERO id: CRD42018088129.

Abstract Background and objectives Nutritional deficiencies, renal impairment and chronic inflammation are commonly mentioned determinants of anaemia. The aim of this study was to investigate the effects of these determinants, singly and in combination, on anaemia in the very old. Method The TULIPS Consortium consists of four population-based studies in oldest-old individuals: Leiden 85-plus Study, LiLACS NZ, Newcastle 85+ study, and TOOTH. Five selected determinants (iron, vitamin B12, and folate deficiency; low estimated glomerular filtration rate (eGFR); and high C-reactive protein (CRP)) were summed. This sum score was used to investigate the association with the presence and onset of anaemia (WHO definition). The individual study results were pooled using random-effects models. Results In the 2216 participants (59% female, 30% anaemia) at baseline, iron deficiency, low eGFR and high CRP were individually associated with the presence of anaemia. Low eGFR and high CRP were individually associated with the onset of anaemia. In the cross-sectional analyses, an increase per additional determinant (adjusted OR 2.10 (95% CI 1.85–2.38)) and a combination of ≥2 determinants (OR 3.44 (95% CI 2.70–4.38)) were associated with the presence of anaemia. In the prospective analyses, an increase per additional determinant (adjusted HR 1.46 (95% CI 1.24–1.71)) and the presence of ≥2 determinants (HR 1.95 (95% CI 1.40–2.71)) were associated with the onset of anaemia. Conclusion Very old adults with a combination of determinants of anaemia have a higher risk of having, and of developing, anaemia. Further research is recommended to explore causality and clinical relevance.